Most of the site will reflect the ongoing surgical activity of Prof. Munir Elias MD., PhD. with brief slides and weekly activity. For reference to the academic and theoretical part, you are welcome to visit
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05-JANUARY-2008 MAHMOUD ASAD ABU-JEISH 24 YEARS
RESIDUAL AFTER TOTAL LEFT BRACHIAL PLEXUS TRACTION INJURY 11 YEARS AGO.
The patient after suffering
RTA 1998 got traction injury of the left
brachial plexus with multiple fractures of
the bones of the left upper limb with crushed
injuries to the soft tissues lower third of the
arm and upper third of the forearm.
MRI of the cervical spine
performed 22-December-1998 showed
pseudomeningocele associated with avulsion
of left C6 and 7 roots.
The patient had total
non-function of the left brachial plexus. with
ugly scar with weak left pectoralis muscle 3/5.
Anaesthesia of the left upper limb at ht upper
third of the arm and below.
The patient was operated
16-March-1999: exploration of the median and
ulnar nerves at the scar site and neurolysis was
performed and continuity of both nerves was
Exploration of the left
brachial plexus was performed 16-May-1999:
bridge anastamosis was used to connect the C4
with the avulsed C6 root, using sural graft.
The patient then came
30-January-2000 with the triceps functioning and
the biceps and the deltoid 3/5, with the
anaesthesia became below the mid third of the
The patient then
26-February-2000 underwent left radial nerve
exploration and sural graft was used to fill the
deformed and missed gap.
The patient came 24-July-2000
with improvement of the biceps brachii and the
brachioradialis muscle 2/3 with the sensation
became down to the mid third of the forearm.
The patient then came
12-August-2002 and after studying the case, he
was advised to undergo cooptation of the
intercostal nerves to the median and ulnar
The patient came
01-January-2008 urging to perform anything to
make him able to use his left hand for support.
His neurologic examination was the same as
before, except that the left deltoid muscle
became worse, due to neglect.
It was explained to the
patient, that the improvement of surgery could
be low as 20% and arthrodesis of the left wrist
must be performed. What the exact plan for the
surgery of the neural tissues will be decided
during operation. The patient accepted the terms
and he was admitted.
Under G.A IOM
monitoring using ISIS Highline Inomed, SEP was
obtained from both median and ulnar nerves.
There was a delay in latency and decrease in
amplitude, but they were obtained from the
Exposure of both median and
ulnar nerves was performed in the axilla. They
were looking excellent in shape. Trying to
obtain CNAP from both nerves was impossible
using different parameters and setups. Using the
stimulator alone without recoding electrode, it
was possible to see some tiny movements in the
ulnar nerve distribution.
Stimulation of the axillary
nerve showed excellent contraction of the
The left II-IV intercostal
nerves were released and sectioned at the site
before giving branches. The I intercostal nerve
was missing. There was a small running motor
nerve running by, which was sectioned to be used
It was decided to make a
cooptation between these four nerves with the
left median nerve. The median nerve was
sectioned at the level after the union of the
lateral and medial branches, and through a
tunnel through the adipose tissue it was
transferred to meet the four nerves.
Under magnification, the four
nerves were stitched to the median nerve. See
It seems that the four twigs
were insufficient to fulfill the median nerve,
but they were the only available source in this
region. Using saphenous graft to bridge with
other intercostal nerves it seemed to be a bad
The wound was closed and
arthrodesis of the left wrist with 10 degrees
dorsiflexion and continuity with third MC bone
was achieved using iliac bone graft and plate
with screws 22-16 mm length.
Cross-anastamosis of the
intercostal nerves is only sufficient to provide
innervation to only one major nerve. See the
picture above and it will be clear, that in no
way it could supply the median and ulnar nerves
together. It is will known that the median nerve
is more important than the ulnar functionally,
for that, in case of their equal non-function,
priority is paid to the median nerve.
This case is a challenging
one from the surgical point and decision making
point and intraoperative monitoring side. There
was no acceptable nerve to obtain for studying
the CNAP, so as to have comparison with the
This case also made a gloomy
picture of the suggested surgical treatment of
paraplegia using the dorsal roots to be
transferred to the lumbo-sacral roots. But. it
is early to be disappointed because the
postganglionic part of the dorsal roots still
having an acceptable diameter, in contrast to
the small diameter intercostal nerves.
In the future in similar
case, it will be preferable to section the
median nerve as proximal as possible, including
the merging branches below the emergence of the
ulnar and the MCN. By doing this, the length of
the graft will be more and the twigs can be
stitched to either of the stumps. More precise
cooptation and more ample to gather the running
twigs of the intercostal nerves.
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After long years TRUMPF TruSystem 7500 is running with in the neurosuite at
Shmaisani hospital starting from 23-March-2014